Specimen Collection: Nose and Throat Swabs (AUS and NZ)

ALERT

Elsevier Clinical Skills covers the principles of this procedure. Follow local guidelines and procedures concerning available equipment, resources and documentation.

Learning Objectives

After completing all elements of the skill, the learner should be able to:

1. Describe the relevant anatomical nose and throat structures pertinent to obtaining a swab.
2. Identify and describe indications for performing a nasal and/or throat swab.
3. Demonstrate the knowledge, skills and attitudes to collect a nasal and/or throat swab.

National Safety and Quality Health Service Standards (AUS), 2nd ed.

Standard and Criterion

Clinical Governance: 1.01, 1.03, 1.06, 1.07, 1.08, 1.11, 1.15, 1.16, 1.18, 1.20, 1.21, 1.22, 1.23, 1.25, 1.27, 1.28
Partnering with Consumers: 2.01, 2.02, 2.03, 2.04, 2.05, 2.06, 2.07, 2.08, 2.10
Preventing and Controlling Healthcare-Associated Infection: 3.01, 3.02, 3.03, 3.05, 3.06, 3.07, 3.08, 3.10, 3.11
Comprehensive Care: 5.01, 5.02, 5.03, 5.04, 5.05, 5.06, 5.14
Communicating for Safety: 6.01, 6.02, 6.03, 6.04, 6.05, 6.06, 6.07, 6.08, 6.09, 6.10, 6.11
Recognising and Responding to Acute Deterioration: 8.02, 8.03, 8.04

RN Standards for Practice (AUS)

Standard and Indicator

Standard 1: 1.1, 1.2, 1.3, 1.4
Standard 2: 2.1, 2.2, 2.5
Standard 3: 3.2, 3.6, 3.7
Standard 4: 4.1, 4.2
Standard 5: 5.1, 5.2, 5.3
Standard 6: 6.1, 6.2, 6.5
Standard 7: 7.1, 7.2, 7.3

EN Standards for Practice (AUS)

Domain, Standard and Indicator

Professional and Collaborative Practice:
Standard 1: 1.1, 1.2, 1.3, 1.4, 1.5
Standard 2: 2.1, 2.2, 2.3, 2.4, 2.7, 2.8
Standard 3: 3.1, 3.9
Provision of Care
Standard 4: 4.1, 4.2, 4.3
Standard 5: 5.2, 5.5
Standard 6: 6.1, 6.2, 6.6
Standard 7: 7.1, 7.2, 7.4
Reflective and Analytical Practice
Standard 8: 8.1
Standard 9: 9.2, 9.3, 9.4
Standard 10: 10.6

Competencies for Registered Nurses (NZ)

Domain and Competency

Domain 1 Professional Responsibility: 1.1, 1.3, 1.4, 1.5
Domain 2 Management of Nursing Care: 2.1, 2.2, 2.3, 2.6
Domain 3 Interpersonal Relationships: 3.1, 3.3
Domain 4 Interprofessional Health Care and Quality Improvement: 4.1, 4.2

Competencies for Enrolled Nurses (NZ)

Domain and Competency

Domain 1 Professional Responsibility: 1.1, 1.3, 1.4
Domain 2 Management of Nursing Care: 2.1, 2.2, 2.3, 2.4, 2.5
Domain 3 Interpersonal Relationships: 3.1, 3.2
Domain 4 Interprofessional Health Care and Quality Improvement: 4.1, 4.2, 4.3

INTRODUCTION

The skill Specimen Collection: Nose and Throat Swab (AUS and NZ) refers to the procedure of taking samples from the surface of the mucosa in the nose and/or throat to identify organisms causing an acute or chronic infection, or to identify asymptomatic carriers of antibiotic-resistant strains. The skill is performed in the healthcare context by registered nurses (RNs) and registered midwives (RMs) and may also be delegated to enrolled nurses (ENs) under the direction of an RN. In order to achieve optimal results, the health professional performing this skill must have a sound understanding of the anatomy and physiology of the upper respiratory tract and be able to perform a focused patient assessment of the upper respiratory tract. Those performing the skill are required to have specimen-handling skills, knowledge of laboratory practices and must adhere to standard and transmission-based precautions.

Theory and evidence base

Anatomy and physiology

The nose and throat are parts of the upper respiratory system (Figure 1). The upper respiratory tract includes the nasal cavity, mouth, pharynx (throat), epiglottis, larynx and trachea (undefined#3">Eisel, 2015).

Nose

The nose is located at the entrance of the respiratory system and is divided into external and internal structures (Tortora & Derrickson, 2012). The internal paranasal sinuses are responsible for humidifying inspired air (Tortora & Derrickson, 2012). The membrane that lines each paranasal sinus contains mucus-producing cells and tiny hair-like cells called cilia. Cilia collect and sweep out pollutants, micro-organisms, and dust and dirt from the sinuses into the nasal cavity (Tortora & Derrickson, 2012). In healthy people, these sinus secretions are moderate in amount and constantly draining into the nasal cavity. From there, the mucus progresses into the nasopharynx from where it is swallowed together with saliva. Only a small amount of mucus drains via the external nares.

Throat (pharynx)

The throat is a funnel-shaped tube about 13 cm long that starts at the internal nares and extends to the level of the cricoid cartilage (Tortora & Derrickson, 2012). It is divided into three regions; the nasopharynx, oropharynx and laryngopharynx (Figure 1). The primary function of the oropharynx is to connect the nasal cavity and the nasopharynx to the laryngopharynx and the larynx for passage of air into the lungs, and to connect the oral cavity with the oesophagus for passage of food into the stomach. The epiglottis is a flap of tissue connected to the larynx, which closes off the trachea during swallowing to prevent food and fluid from entering the lungs (Solomon, 2016).

Pathophysiology of upper respiratory tract infections

Acute inflammation and infections of the upper respiratory tract include epiglottitis, influenza, pharyngitis, tonsillitis and pertussis. These infections can cause symptoms including profuse rhinorrhoea, nasal congestion, purulent discharge and cough. Patients may experience pain on swallowing, a hoarse voice and fever (Joanna Briggs Institute [JBI], 2016b). Common micro-organisms that can cause these conditions and/or are frequently identified by nose/throat swab include the following.

Bacteria

• Bordetella pertussis
• Multiple resistant Staphylococcus aureus
• Streptococcus
• Vancomycin-resistant Enterococcus

Viruses

• Adenovirus
• Influenza virus (JBI, 2015)
• Parainfluenza virus
• Respiratory syncytial virus (RSV)

Fungi

• Aspergillus species
• Candida species

Indications for performing a nose and/or throat swab

Nose and/or throat swabs are indicated to identify the causative micro-organisms of a clinical infection or to confirm colonisation with a multiple antibiotic-resistant organism.

Once identified, antimicrobial, antiviral or antifungal therapy tailored to specifically manage and treat the micro-organism can be initiated.

Types of swabs

Both viral and bacterial/fungal swabs are typically presented as either a long, dry stick with a Q-tip end (Figure 2) or a long, dry stick with a fine sponge end (Figure 3). Most bacterial/fungal and viral swabs are inserted into either a liquid or gel medium immediately after collection (Figure 4). The presence of this medium preserves the micro-organisms during transport to the laboratory.

Equipment preparation

The pathology request form should be closely consulted before the procedure to prepare the correct type of swab. If the health professional is unsure which type of swab to use or where to collect the sample from, clarification should be sought from the receiving pathology laboratory or the person who ordered the test.

Pre-collection assessment

Prior to the collection of nose/throat swab(s), obtain a focused history of current symptoms and the prevailing complaint, including pain. Ask the person about any relevant surgical history, trauma or known anatomical variations likely to complicate the collection procedure. Assess the person's ability to open their mouth wide, protrude their tongue and move their neck. Then inspect the entrance of the nasal cavity for evidence of nasal polyps, septum deviation or lesions. Finally, inspect the nose and throat for clinical signs of infection, including swelling, redness, inflammation, increased amount of mucus, rhinorrhoea and tenderness (Scully, 2015).

Timing of collection

All swabs should be obtained before initiating antimicrobial therapy to ensure that the antimicrobial therapy does not impact on the results.

Positioning for swab collection

It is important to position the person comfortably in order to collect the swab as accurately and efficiently as possible. A seated position is recommended (JBI, 2016a). An active gag reflex may make it difficult to obtain a throat swab. However, the gag reflex may be less active if the person is sitting up straight and leaning forward slightly (Scully, 2015). It is important to educate the person that the procedure will only take few seconds and therefore the person may be able to control gagging for this time (Scully, 2015). To ensure visualisation of the necessary throat and nasal anatomy and the appropriate areas to swab, it is important to ensure a good light source is available.

Nose and throat swab collection

The health professional performing a swab procedure may be required to take both a nasal and a throat swab, depending on the target micro-organisms. A separate swab should be used for each distinct area of collection. If the suspected causative micro-organism is a fungus, an additional swab may be required.

Nose swab

A nasal swab should be rotated over any inflamed areas, visible exudate or rhinorrhoea from the anterior nare (Scully, 2015) to ensure that infective micro-organisms are collected. This should be done quickly and gently to ensure the person's comfort.

Specimens to detect viral micro-organisms should be taken during the first three days after the onset of clinical symptoms (JBI, 2016a) as the viral load present in the rhinorrhoea decreases after this time.

Throat swab

A throat swab should be collected by instructing the person to open their mouth widely, using a tongue depressor to gently depress the tongue to allow easy access to the pharynx.

The throat swab should be rubbed over any reddened areas with lesions, inflammation or visible exudates from the posterior pharyngeal wall and tonsillar regions of the throat (JBI, 2016b) to ensure that the infective micro-organisms are collected. This should be done quickly but gently to ensure patient comfort. It is important to avoid swab contact with any other area of the tongue or mouth to prevent contamination with resident oral flora. Evidence is lacking about the utility of performing routine throat swabs in acute pharyngitis, because the treatment course is often unchanged by the swab result (JBI, 2016b). If acute epiglottitis is suspected, a throat specimen should not be collected because the trauma from the swab may cause increased oedema, resulting in airway occlusion.

Post-collection considerations

Once collected, swabs must be immediately placed into their airtight container, as anaerobes die when exposed to oxygen. Anaerobe bacteria play an important role in complications of upper respiratory tract infections and can affect the efficacy of antibiotic treatment directed at bacteria usually treatable with penicillin (Brook, 2002). In contrast to the common aerobe bacteria found in respiratory infections, anaerobe species are harder to isolate and culture, and more susceptible to unfavourable conditions during transport (Brook, 2002). If a specimen cannot be sent to the laboratory immediately, it should be stored in a designated refrigerator that maintains a constant 4°C temperature to minimise degradation of the sample (JBI, 2016b).

Laboratory processing of the swab

The type of analysis is determined by the tests requested and the type of swab used. Once received in the laboratory, specimens undergo either:

• Microscopy, culture and sensitivity testing (MCS): the viewing of the sample under the microscope, while culturing of swabs on agar plates to enable bacterial count followed by sensitivity documentation of a variety of antibiotics.
• Polymerase chain reaction (PCR): involves the heating and cooling (thermal cycling) of the sample in a laboratory and is a method used to document specific DNA sequencing from the cells in a sample of appropriate fluid or tissue, such as that sampled in throat and/or nasal swabs. PCR analysis is effective in identifying micro-organisms which are difficult to grow in a culture (Lewis, 2015).

MATERIALS

PROCEDURE

1. Identify the indication/rationale for nose/throat swab collection by assessing the person's clinical condition.

Rationale: To ensure that collecting the nose/throat specimen is appropriate to the person's condition (ACSQHC, 2017, Standard 6).

2. Ensure that the request form is completed in full with at least three approved patient identifiers, specimen type, requested test(s), appropriate clinical information and signed and dated by the requesting medical practitioner.

Rationale: To ensure the person can be identified and the specimen/sample matched correctly to the requested test (ACSQHC, 2017, Standard 6).

3. Gather the necessary equipment and supplies.

Rationale: To ensure safe collection and storage of the nose/throat swab sample.

4. Perform hand hygiene.

Rationale: To reduce the risk of cross-contamination and cross-infection and to comply with infection control principles. Perform hand hygiene before and after every episode of patient contact and after any activity or contact that potentially results in hands becoming contaminated in line with the ‘5 moments for hand hygiene’ (ACSQHC, 2017, Standard 3; HHA, 2016; NHMRC, 2019, pp. 55–6). Hand hygiene is the single most effective action to reduce healthcare-associated infections (ACSQHC, 2017, Standard 3; HHA, 2016).

5. Engage in therapeutic communication.
1. Introduce self (name and function/designation).
2. Confirm the person's identity (minimum of three identifiers: e.g. full name, date of birth, medical record number).
3. State intent, outline the procedure and answer any questions.

Rationale: (a) To establish rapport, (b) to ensure the person's safety and (c) to promote person-centred care, which requires the person to have a clear understanding of what task is planned and why the task is required in order to give consent (ACSQHC, 2017, Standards 2 and 6).

6. Gain consent (from the patient and/or caregiver).

Rationale: To demonstrate the healthcare professional's respect for the patient's autonomy and to give the patient permission to refuse treatment or procedures (ACSQHC, 2017, Standard 2).

7. Ensure the privacy and comfort of the patient.

Rationale: To facilitate an environment that promotes dignity for the patient (ACSQHC, 2017, Standard 2).

8. Help the person to sit upright.

Rationale: To avoid activation of the gag reflex and increase comfort for the person.

9. Ensure a good light source.

Rationale: To allow visualisation of nasal and throat anatomy.

10. Perform hand hygiene and apply PPE as required by the person's condition in accordance with standard or transmission-based precautions. Additional PPE may be required for those on droplet or airborne precautions.

Rationale: To reduce the risk of cross-contamination and cross-infection and to comply with infection control principles (NHMRC, 2019; ACSQHC, 2017, Standard 3). Hand hygiene is the single most effective action to reduce healthcare-associated infections (ACSQHC, 2017, Standard 3; HHA, 2016). Use PPE in accordance with standard precautions or, if required, transmission-based precautions as indicated (NHMRC, 2019).

11. Assess the nasal mucosa, sinuses and/or throat, noting any reddened areas with lesions, inflammation or visible exudate.

Rationale: To ensure swabbing of appropriate areas to allow for accuracy of results (JBI, 2015; JBI, 2016a).

12. Open the sterile swab specified by the pathology service provider without touching the swab itself or the inside of the container.

Rationale: To avoid inaccurate test results caused by a contaminated sample (ACSQHC, 2017, Standard 3).

13. Collect the swab as per local policies and guidelines.
1. Perform the following steps for a throat swab.
1. Instruct the person to open their mouth widely and slightly depress the tongue with the tongue depressor.

Rationale: To ensure easy access to the pharynx.

2. Quickly, but gently, rub the swab over the prescribed area, usually the posterior pharyngeal wall and/or tonsillar regions or any area with lesions, inflammation or visible exudate.

Rationale: To ensure patient comfort and accuracy of results in relation to possible infective micro-organisms, as results can vary according to the site in which the sample was taken (JBI, 2016a; JBI, 2015).

2. Perform the following steps for a nasal swab.
1. Carefully insert the swab into the anterior nare (nostril) until it reaches the portion of mucosa that is inflamed or contains exudate.

Rationale: To ensure accuracy of results as results can vary according to the site in which the sample was taken (JBI, 2016a; JBI, 2015).

2. Rotate the swab quickly but gently over the inflamed or exudative area.

Rationale: To ensure patient comfort.

14. Inspect the specimen/sample for colour and consistency and note any unusual odour.

Rationale: To obtain additional clinical information relevant for accurate diagnosis, management and recognition of acute deterioration (ACSQHC, 2017, Standard 8).

15. Put the swab inside the container without contaminating the exterior with specimen/sample matter and secure the lid. Ensure the swab is positioned within the transport medium if present.

Rationale: To avoid exposing the environment or personnel to body fluids or human tissue residue. Should the exterior of the specimen container become soiled, treat it like a body fluid spill and clean accordingly before proceeding (ACSQHC, 2017, Standard 3).

16. Offer the person tissues to blot their nose and attend to mouth care as appropriate.

Rationale: To ensure comfort of the person.

17. Remove gloves, dispose of PPE and attend to hand hygiene according to the ‘5 moments for hand hygiene’.

Rationale: To reduce the risk of cross-contamination and cross-infection (NHMRC, 2019; ACSQHC, 2017, Standard 3). Hand hygiene is the single most effective action to reduce healthcare-associated infections (ACSQHC, 2017, Standard 3; HHA, 2016).

18. Label the specimen container with at least three approved patient identifiers, specimen type, collection site, date and time of specimen/sample collection and specimen/sample number (if a series of specimens is being collected).

Rationale: To ensure the specimen/sample is clearly identified and matched to the correct person to avoid error, rejection or delay in processing due to incorrectly or insufficiently labelled specimens/samples (ACSQHC, 2017, Standard 6).

19. Ensure the person is safe, positioned comfortably and has access to the call bell and personal items.

Rationale: To avoid adverse outcomes and to ensure that the person is content.

20. Complete the request form by adding date and time of specimen collection, and if appropriate, collection site and specimen number (if a series of specimens is being collected). Sign, print name and provide contact details to finalise, if mandated by local protocol.

Rationale: To ensure the request form is complete to avoid error, rejection or delay in processing of the specimen/sample (ACSQHC, 2017, Standard 6).

21. Place the specimen container in a designated specimen transport bag, seal it and insert the request form into the pocket of the bag. Package specimens/samples for urgent transport or processing, according to local protocol.

Rationale: To protect the environment, personnel and the request form from contact with the specimen/sample material (ACSQHC, 2017, Standard 3).

22. Initiate immediate transport of the specimen/sample to the receiving laboratory, if urgent, or place the correctly labelled specimen/sample under suitable storage conditions in a designated area to await transport.

Rationale: To ensure the sample is transported for testing without delay or stored appropriately until transport. Comply with local policies and procedures to ensure safe and timely transport to the laboratory (ACSQHC, 2017, Standard 8).

23. Document the specimen/sample collection and any associated observations. Report any adverse events during collection according to local policies and guidelines. Ensure that the specimen number is documented if a series of specimens is being collected.

Rationale: To ensure all patient care documentation, which is mandatory and essential for patient safety, is completed (ACSQHC, 2017, Standard 6).

CULTURAL CONSIDERATIONS

Assessment prior to any nose and/or throat swab should consider specific cultural needs. Māori patients believe the head is ‘tapu’ or sacred (Medical Council of New Zealand, 2008) and therefore offering an explanation and obtaining permission is in keeping with principles of cultural safety.

REFERENCES

Australian Commission on Safety and Quality in Health Care (ACSQHC). (2017). National Safety and Quality Health Service Standards (2nd ed.). Retrieved from:www.safetyandquality.gov.au/sites/default/files/2019-04/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf

Brook, I. (2002). Anaerobic bacteria in upper respiratory tract and other head and neck infections. Annals of Otology, Rhinology & Laryngology. 111(5 pt 1):430–40.

Eisel, S.J. (2015). Nursing assessment: respiratory system. In: Brown, D., Edwards, H., Seaton, L. & Buckley, T. (eds). Lewis's Medical-surgical Nursing (4th ed.). Sydney: Elsevier, pp. 477–99, 1687–9.

Hand Hygiene Australia (HHA). (2016). The 5 moments for hand hygiene. Retrieved from: www.hha.org.au/home/5-moments-for-hand-hygiene.aspx

Joanna Briggs Institute (JBI). (2015). Throat swab (recommended practices). Retrieved from: connect.jbiconnectplus.org/Default.aspx

Joanna Briggs Institute (JBI). (2016a). Nasal swab (recommended practices). Retrieved from: connect.jbiconnectplus.org/Default.aspx

Joanna Briggs Institute (JBI). (2016b). Upper respiratory tract infections (paediatrics): specimen collection (evidence summary). Retrieved from: connect.jbiconnectplus.org/Default.aspx

Lewis, S.L. (2015). Genetics and genomics. In: Brown, D., Edwards, H., Seaton, L. & Buckley, T. (eds), Lewis's Medical-surgical Nursing (4th ed.). Sydney: Elsevier Australia, p. 171.

Medical Council of New Zealand (2008). Best Health Outcomes for Māori. Retrieved from: www.mcnz.org.nz/assets/News-and-Publications/Statements/Best-health-outcomes-for-Maori.pdf

National Health and Medical Research Council (NHMRC). (2019). Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia. Retrieved from: www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019

Scully, N. (2015). Preserving oxygenation. In: Crisp, J., Taylor, C., Douglas, C. & Rebeiro, G. (2016). Potter and Perry's Fundamentals of Nursing—Australian version (5th ed.). Sydney: Elsevier, pp. 1241–318.

Solomon, E.P. (2016). Introduction to Human Anatomy and Physiology. Missouri: Saunders Elsevier.

Tortora, G.J. & Derrickson, B. (2012). The respiratory system. In: Tortora, G.J. & Derrickson, B. (eds). Principles of Anatomy and Physiology (13th ed.). Hoboken, New Jersey: John Wiley & Sons, pp. 918–66.

ADDITIONAL RESOURCES

Crisp, J., Taylor, C., Douglas, C. & Rebeiro, G. (2017). Potter and Perry's Fundamentals of Nursing—Australian version (5th ed.). Sydney: Elsevier.

Nicol, M., Bavin, C., Cronin, P., Rawlings-Anderson, K., Cole, E. & Hunter, J. (2012). Essential Nursing Skills (4th ed.). Edinburgh: Mosby Elsevier.

Nursing and Midwifery Board of Australia (NMBA). (2008). Code of Professional Conduct for Nurses. Retrieved from: www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Patton, K. & Thibodeau, G. (2015). Anatomy & Physiology (9th ed.). St Louis: Elsevier.

Rebeiro, G., Wilson, D., Scully, N., & Jack, L. (2017). Fundamentals of nursing: clinical skills workbook (3rd ed.). Sydney: Elsevier.

Nursing Council of New Zealand. (2015). Competencies for Registered Nurses. Retrieved from: www.nursingcouncil.org.nz

Nursing Council of New Zealand (NCNZ). (2011). Guidelines for Cultural Safety, the Treaty of Waitangi and Maori Health in Nursing Education and Practice. Wellington, NZ: NCNZ.

ACKNOWLEDGEMENTS

Elsevier Australia would like to thank the following people who contributed to this skill: Christina Parker (Author), Elfi Ashcroft (Multimedia editor), Lise Duggan (Section editor) and Elizabeth Matters (Lead editor).